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1. Appliance or fitting /appliance or fitting model (product, type, batch or serial number): 2. Name and address of the manufacturer and, where applicable, his authorised representative: 3. This declaration of conformity is issued under the sole responsibility of the manufacturer.

4. Object of the declaration (identification of the appliance or fitting allowing traceability; where necessary for the identification of the appliance or the fitting, an image may be included): description of the appliance or the fitting.

5. The object of the declaration described in point 4 is in conformity with the relevant Union harmonisation legislation: … (reference to the other Union acts applied).

6. References to the relevant harmonised standards used or references to the other technical specifications in relation to which conformity is declared: 7. The notified body … (name, address, number) … performed … (description of intervention) … and issued the certificate(s): … (details, including its date, and, where appropriate, information on the duration and conditions of its validity).

8. In the case of fittings, instructions on how the fitting should be incorporated into an appliance or assembled to constitute an appliance in order to assist compliance with the essential requirements applicable to finished appliances.

9. Additional information: Signed for and on behalf of: … (place and date of issue): (name, function) (signature):